Small intestine peroral biopsy in coeliac children

Peroral endoscopic duodenal biopsy in infants and children

Peroral endoscopic duodenal biopsy was used in the diagnosis and follow-up of forty-nine infants and children with suspected small intestine disease. Their ages ranged between one month and 12 years. Fifty-four upper gastrointestinal endoscopy procedures were performed and 139 biopsies were taken. The mean procedure time was 3.2 min with a range of 1.5-5.5 min. There were no complications. Tissue adequate for histopathologic examination was obtained in all but one of the fifty-four procedures. On the basis of this experience we think that peroral endoscopic duodenal biopsy is faster, safer and as diagnostic as conventional suction biopsy in infants and children. It is also more informative when other diseases of the upper gastrointestinal tract are suspected.

[Intestinal disaccharidase and alkaline phosphatase activities of jejunal biopsies in small bowel diseases of children (author's transl)]

Intestinal disaccharidase activities were determined in 294 jejunal biopsies obtained from 254 children with various disorders of the small bowel, and alkaline phosphatase activity was measured in 251 biopsies. In normal mucosa a broad range of enzyme activity was found corresponding with the data in the literature. A primary disaccharidase deficiency was observed in 5 children with congenital sucrase-isomaltase deficiency and in a 12-year-old Egyptian boy with acquired lactase deficiency. A secondary generalized depression of disaccharidase activity and a diminution of alkaline phosphatase activity existed chiefly in patients who had severe or moderate mucosal damage, also in active coeliac disease and during gluten loading, in protracted diarrhoea of infancy, chronic malabsorption of unknown origin and agammaglobulinemia. During remissions enzyme activities recovered together with mucosal improvement. Low levels of enzyme activities were also seen in some cases of protracted diarrhoea of infancy and chronic malabsorption of unknown origin although only mild mucosal lesions were demonstrated.

Failure of laboratory and radiological studies to predict jejunal mucosal atrophy

Of 58 children with suspected malabsorption, 27 were shown to have subtotal or partial atrophy, and 31 had normal mucosal histology. Oral glucose tolerance tests, faecal fat excretion, D-xylose excretion tests, Prosparol absorption studies, haematological investigations, and radiological examination of the small bowel failed to distinguish these two groups and frequently gave misleading results. It is concluded that in suspected coeliac disease small intestinal biopsy should be performed as a primary investigation.

Coeliac disease during the teenage period: the value of serial serum folate estimations

A group of teenage coeliac patients has been followed at three monthly intervals in the Outpatient Department to assess their progress and also to monitor their ability to maintain a gluten-free diet. After a follow-up period of four to six years a detailed reassessment was carried out in hospital on 10 patients, only five of whom had persevered with a gluten-free diet. The jejunal mucosal histology of those patients who did not persist with a gluten-free diet remained ;flat' although these patients appeared to have remitted clinically. Those subjects who did persist with a gluten-free regime had a normal or near normal mucosal histology. It was difficult on the basis of clinical, haematological, or biochemical criteria to separate the two groups. The best single assessment of whether these patients were maintaining a gluten-free diet was serial serum folate estimations. It is often extremely difficult to say whether teenage coeliac patients are keeping to their diet unless repeated jejunal biopsies are obtained, and this study suggests that serial serum folate estimations can act as a reasonable criterion of whether subjects are maintaining a gluten-free regime.

110 children with coeliac disease, 1950-1969

110 children with coeliac disease investigated over a period of 19 years are presented in 2 groups, 74 children presenting under 4 years and 36 over 4 years. Sixty per cent of the older children showed extreme stunting of growth, while 28% in the younger group at referral were on or below the 3rd centile. 75% of the younger children were anaemic as compared with over 90% of the older children. Since 1952 all patients have been treated with a gluten-free diet, but in acute cases fluids only were allowed until dilatation of the small bowel had subsided. Thereafter, a low-fat-milk, and gluten-free diet was introduced in easy stages. Nearly all the younger children showed a good response to treatment, and an average weight gain of 1·6 kg was recorded 2 months after treatment had begun. There was no clinical evidence of lactase deficiency. Relapses occurred in every child who had returned to a gluten-containing diet for any length of time. In younger children symptoms soon became apparent, but in the older group symptoms were sometimes delayed for months—or even years. Methods for detecting such subclinical relapses are described. Forty-four children were followed up for periods of 8 to 19 years. 20 children who remained on a gluten-free diet gained weight, grew normally, and had no complications. The remainder, who did not, developed suboptimal growth and chronic ill health and were prone to diarrhoeal attacks, iron deficiency, and megaloblastic anaemia. 2 developed dermatitis herpetiformis. One had a crisis at pregnancy. Reasons are given for recommending a life-long gluten-free diet.

Disease of the small bowel in childhood

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Prognosis in early adult life of coeliac children treated with a gluten-free diet

Long-term follow up of 57 young adults with coeliac disease diagnosed in childhood showed that 13 had relapsed clinically and had resumed a gluten-free diet Of the remainder, who were taking a normal diet and were apparently normal, 19 had low serum folate levels and 11 low serum iron levels. Pregnancy was found particularly likely to provoke an overt relapse.Only six patients were found to be stunted in height, while the menarche had occurred within the average range. The study also confirmed the very low present-daymortality rate of coeliac disease in childhood, which at the Hospital for Sick Children in London has been 0.4% between 1951 and 1968. In view of the finding that childhood coeliac disease usually persists, even though not causing symptoms, it is suggested that the use of a gluten-free diet should be lifelong.

Cytochemical and ultrastructural studies of the intestinal mucosa of children with celiac disease

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Dissecting microscope appearance of small bowel mucosa in children

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